Kurikulum vitae

• dr Finny Fitry Yani SpA(K)

• Staf Respirologi Anak

FK Unand RS M Djamil
• Sp1 Anak 2004
• Fellowship Respi anak FKUI RSCM
• Konsultan Respirologi Anak : 2011
• Shortcourse Pediatric TB : Capetown, South
Africa 2011
• Organisasi : Komite CPD IDAI Sumbar
• UKK Respirologi Anak IDAI
Inhalation treatment
for non-asthma pediatric patient :
is it useful?

The 7th Indonesia Pediatric Respiratory Meeting

Semarang, Februari 2017

Finny Fitry Yani

UKK Respirologi IDAI
Bagian Ilmu Kesehatan Anak
RS dr. M. Djamil/FK Unand, Padang
 Case
A, baby 6 month
Is it useful give
inhalation for
Fever, cough and rhinorrea
for 2 days this baby?
Sometimes mother hears
noisy breathing from her
baby , and she ask
pediatrician to give the baby
‘asap’ .. ( uap )
RR 30x/menit, no wheezing
 Objectives

Better knowledge about usefullness inhalation

therapy in child with respiratory symptoms

More effective and precise of inhalation therapy

for children due to evidence based
Inhalation therapy
= Aerosol therapy

Disease

Drug

Device

Nebulizer
 What’s cases ?

Common cold?

Wheezy infant? Asthma  main

indication
Croup d’s ? bronchodilator
Bronchiolitis ?

Bronchiectasis

Pneumonia ?

BPD? Cystic fibrosis ?

 Common cold ?
• Do you gave inhalation therapy for your patient with
common cold?
YES ? NO ?
• Which drug ? β2 agonist ? Isotonic saline?

• None guidelines and review

recommended aerosol therapy
What is the evidence ? for common cold treatment

• Intranasal ipatropium : 3 RCT

no benefit, 1 RCT no
improvement in rhinorrhea
symptoms Allan, CMAJ, 2014
 Wheezy infant ?

No difference in the reduction

Inhalation of B-2 agonists of clinical symptoms, duration
of hospitalization or increase
and ipatropium bromide, in oxygen saturation.

Inhalation of B-2 agonist Preschool wheeze 

reduce long of stay
and hypertonic saline (Ater et al, Pediatrics 2012)
 Laringotrachecobronchitis
(Croup’s )

Nebulized steroids can accelerate loss of the child's

symptoms as effective as nebulized epinephrine

Croup symptoms disappear two until three hours after

nebulized with budesonide.

Nebulized adrenaline 0,4-0,5ml / kgBW liquid 1: 1,000 with a

maximum dose of 5ml, is useful in the repair of croup
score and decrease the likelihood of hospitalization.
 Bronchiolitis ?

What do we do in practice?

• Dutch survey: Evidence ?

AAP, Chochrane
• 42% bronchodilators for bronchiolitis
routinely, only 8% prescribes this as a
trial treatment.
• 8% prescribes hypertonic saline
• 14% isotonic saline
• 3.4% ICS

Courtesy slide from Hetti Jansenn

 Evidence for Bronchiolitis ?
• Statistically significant but
clinically minimally relevant
Bronchodilators in
improvement
bronchiolitis
• Small short-term
improvements in clinical scores

•404 infants with bronchiolitis:

Racemic adrenaline randomized controlled:
NEJM 2013 Skjerven et al No difference hospital stay for
adrenaline vs saline
Shorter hospital (13.5 hours)
 Bronchiolitis

• No effect of ICS for prevention

ICS in bronchiolitis: of post-bronchiolitic wheezing
Cochrane Database 2013

• Different conclusions of studies:

some show significantly shorter
Hypertonic saline in hospital stay (1 day) and
bronchiolitis Significant improvement in
Cochrane review 2013 clinical symptoms score.

• Overall no effect on length of

stay in Hospital
 Summary of Recent Evidence
for Therapies Used for Bronchiolitis
Courtesy from Hetti Jensenn slide

Therapy Summary Recommendation

Bronchodilators No improvement in duration No routine use
of illness or hospitalization
May improve short-term
clinical scores in a subset of
children
Use only after proven benefit
in a trial of therapy, if chosen
as an option

Inhaled Corticosteroids No improvement in duration No routine use

of illness or hospitalization

Leukotriene receptor No improvement in duration Not recommended

of illness
antagonists
Inhaled hypertonic May reduce length of None
inpatient hospitalization
saline
Inhaled epinephrine No shorter hospital stay , no none
difference on symptoms, Pediatrics 2010
compared with saline
 Bronchiectasis ?

ICS + LABA:
Cochrane review 2014
No significant difference between
groups could be found for
QOL
lung function,
exaxerbation,
adverse event
Widespread applicability of these
results is substantially limited.
Courtesy from Hetti Jensenn slide
 Pneumonia ?

Inhaled β-agonist ? None guidelines recommended as

one of the modality treatment of
pneumonia

Inhaled AB ? In cases of severe pneumonia

with mechanical ventilation

 cure rate very different

Normal saline + (60% vs 36,67%) but not
ambroxol ? statistically significant
 (p > 0,05)
 Bronchopulmonary displasia
NICU use

Inhaled steroid for BBLR? EARLY : prevention BPD/CLD

• Controversial results
• No significant reduction in
rate of CLD

LATE : prevention BPD/CLD

initiated at ≥ 7 days of life for preterm
infants at high risk of developing BPD
cannot be recommended at this point
in time.
Courtesy from Hetti Jensenn slide
 Bronchopulmonary displasia
NICU use

Bronchodilator for BPD/CLD?

Tin W and Wiswell T. Drug therapies in bronchopulmonary dysplasia: debunking the
myths. Semin Fet & Neon Med 2009

Several studies: variable results, including improvement, no

change or even worsening
• No RCT to review meaningful clinical outcomes following
beta-receptor agonist therapy,
• The usefulness of beta-receptor agonist therapy in treating
infants with CLD remains unknown.

Courtesy from Hetti Jensenn slide

 Cystic Fibrosis ?

Inhalation ?
•hypertonic saline,
•acetylcysteine
•mannitol

• Remain controversial, benefit

and worseness effect
• Many study were developing
• Autosomal resesive,
• Chromosom 7 mutation
• Epithelial cell respiratory tract
• Acumulative and viscous mucus
 Special consideration
• To reduce the volume of mucus secretion or enhance
clearance of airway  after management of basic
diseases already done

• Clinical improvement is difficult to measure, but

observable indicators  patients felt better and
increased sputum secretion.

• Be careful during the acute episode sputum retention

 effective cough  precaution for children with CP,
weakness of cough stimulation, accumulate
 Conclusions
• The use of inhalation therapy is mostly done based on
experience rather than scientific evidence.

• A lot of what we do is not evidence based, while there is

evidence for another strategy

• But often there is no evidence.

• Therefore, it needs clinical evaluation and critical judgment

according to the situation of the patient
 Thank You

UKK Respirologi
Happy, big and
dynamic Family